We have examined patients' perspectives and preferences at the level of individual consultations and identified ways in which lack of participation leads to misunderstandings that have actual or potential adverse consequences for taking medicines. We have not presented other kinds of misunderstanding in this paper. The identification of these misunderstandings is based on interview data from both parties as well as consultation data. Models of shared decision making emphasise the need for an exchange of information, and the findings show the consequences of the failure to exchange information.12,13
Both parties to the consultation have relevant information to exchange and it was not possible to make judgments about which party contributed most to each misunderstanding. The findings show specific ways in which patients' expectations are not elicited or expressed and underline the importance of researching patients' priorities at the consultation level. The fact that general practitioners sometimes write inappropriate prescriptions to preserve relationships with their patients is well established,14
and these results confirm the adverse consequences of this. The findings also confirm the conclusion reached by others that asking patients about satisfaction is an insufficient way of assessing the outcome of consultations.
The participating doctors were a selected sample of general practitioners willing to participate in the research and who may have had a particular interest in communication. If these doctors have misunderstandings with their patients it is likely that less interested doctors would also experience these problems. The doctors were chosen to represent a range of locations and types of practice, and misunderstandings occurred across the whole sample.
What is already known on this topic
It is well established that patients prefer doctors who listen and encourage them to discuss all their problems, but also that patients are often passive in consultations
What this study adds
This qualitative study, having captured patients' and doctors' perspectives and the actual content of consultations, shows a range of misunderstandings and their actual or potential adverse consequences for taking medicines
These misunderstandings seem to be associated with patients' lack of participation in the consultation and are often based on inaccurate guesses and assumptions on the part of both doctors and patients
An educational intervention is being developed on the basis of these findings
Clinicians may be tempted to think that they know their patients well enough not to have to verify their own assumptions. Our data suggest that many assumptions made by doctors, although reasonable in themselves, are not correct in particular circumstances, and that doctors need to check their assumptions in each consultation. It has already been established that doctors' perceptions of patients' expectations are a major influence on prescribing decisions.15,16
Although we have focused on misunderstandings, we also identified examples of good practice. In particular, one doctor asked patients directly what they thought about taking medicines. In this way misunderstandings were avoided, and in one case this doctor gave the patient a deferred prescription, which was an acceptable outcome for the patient.17
It is clearly difficult to avoid all misunderstandings within the time constraints of most general practice consultations, although some doctors in our study consultations did succeed in doing so.
The question remains as to whose responsibility it is to improve communication in the consultation. Arguments can be made in favour of changing either doctors' or patients' behaviour, and changes on both sides are likely to be necessary. However, given the power imbalance in many consultations the onus would seem to be on doctors to elicit patients' ideas and expectations thereby showing that this information is a valuable and necessary contribution to the consultation. In addition to listening, doctors also need to ask the right questions. We are currently developing an educational intervention that builds on these findings.